The SPECIALIST'S OFFICE => Ligament damage => Cruciate ligaments => Topic started by: The KNEEguru on January 26, 2010, 11:00:07 PM

Title: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: The KNEEguru on January 26, 2010, 11:00:07 PM
Ian McDermott has prepared another paper for us - Graft Choice in ACL reconstructions - The Place of Allografts -
Title: Re: Graft Choice in ACL reconstructions - LARS choice?
Post by: kneelobo on April 19, 2010, 07:05:01 PM
Hi. I have been diagnosed with a fully torn ACL. Apparently I've had this for over 10years, but I did nothing about it. I just did accupuncture each time it twisted, and wore knee braces and everything was kinda OK for a while, and then over the last 2 years I am not able to function properly in my physical activity.
I am 36years old. Used to play Rugby / Football (Soccer), quite alot from age 18 to 31.
At the moment, I found a surgeon who will do LARS surgery. I got the MRI done, and it confirmed total ACL tear.

On this site found few people with good experiance with this type of surgery, but doesn't seem to be a universally accepted procedure for some reason.

Can anyone confirm if LARS could be an acceptable choice for my condition since I left the injury un-attended for so long.
Bearing in mind, I won't play anymore contact sports, just regular jogging, and weight training.

One surgeon Says its the best,  another says no.  I am confused.
I can't afford to be off work for too long, so this procedure looks very attractive.
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: tez27 on April 19, 2010, 07:32:32 PM
Check out Jays post op diary as he had his acl reconstructed using lars you might find some information on there
Sorry I cant be any more help, I'm still waiting my aclr but think I will be going for the hamstring graft though have to still have the conversation with my o.s about what he thinks will be the right choice for me.
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: LarryAbes on April 22, 2010, 12:47:49 AM

I am currently laid up with my 2nd acl surgery. I tore my right knee about 8 years ago play basketball and they used the middle 3rd of my patellar tendon as the graft and it worked out just great for me. At the time I tore my acl, mcl and meniscus and i haven't had a problem since, it feels great.

I just tore my left acl a few weeks ago playing basketball again and had surgery on 4/8. They used the patellar tendon again and it feels pretty good for being 2 weeks out of surgery. I heard good things about the hamsting too, but i have heard some horror stories about cadavers (but you never see people use this nowadays)

good luck with your surgery and my one piece of advice is take the physical therapy very seriously, and really work at it-- if you don't the surgery won't be a success

Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: jamiec123 on May 18, 2010, 02:45:14 PM
hi kneelobo

As Tez said, I had my ACL reconstructed by LARS about 8 weeks ago.  So far, so good!  If you want to know anything, feel free to ask!!

Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: Debban on June 06, 2010, 01:52:07 PM
I had my acl reconstructed 2 years ago with an allograft, tibialis anterior tendon. Worked out great. The knee is strong and stable and PT went well.
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: tony1233 on July 26, 2010, 09:13:42 PM
hi guys,

any good stories about allografts ? Particularly about hammy allografts ? I will be getting my ACL reconstruced in 2 weeks using this from a cadaver and I'm just curious as to how it should go !


Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: jamiec123 on July 30, 2010, 12:38:36 PM

im 18 weeks post ACLr with LARS.  Ive been running for the past 4 weeks and have even been playing a bit of football (only small sided games with passing, no-one is allowed to tackle me ha ha).

The best bit of advice i can give you is listen EXACTLY to what the dr says.  and make sure you rest it!  The more u keep the leg up and the more you ice it, the quicker it will heal!!

Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: tony1233 on July 31, 2010, 04:23:03 PM
Hi jay!

wow, you must be doing well, any footy at 14 weeks is great!  Thanks for the advice Jay, I will keep that in mind throughout the whole process!

Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: jamiec123 on August 02, 2010, 11:14:59 AM
Hi Tony,

Well to be honest, i probably shouldnt be playing in the games, my physio gave me the go ahead to do most other things and ive kind of taken it upon myself to get involved in the small sided games.  I definitely wont be playing competetively for a while!!

Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: tony1233 on August 02, 2010, 02:15:44 PM

lol that sounds like a thing that most guys would do anyway ;) I can see myself refereeing hockey twards the end of this season. I'm hoping to be back to being able to play competative by next season, not the begining because it starts in april or may but, I'm aiming for early july. I know I'll have to strengthen my knee immensly in order to achieve this but, I plan on doing that anyway. At what point did you begin training again ? How did they fix your graft on your femur ? Sorry for all the questions I'm just trying to get an idea of how I'll be post Op!


Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: jamiec123 on August 03, 2010, 09:44:47 AM
Hi Tony,

Honestly feel free to ask anything, i know before and after my ops, this forum was invaluable to me!!

Well i started running again at about 14 weeks and since then i have been steadily increasing my training to include more football related things such as mini hurdles, ladders, shuttle runs, weaving between posts, dribbling the ball etc.  The physio had my on an exercise bike as soon as possible, probably about 2-4 weeks.

With regard to fixing the graft, they drilled my femur and tibia and attached the graft using screws.  I believe the idea is that eventually my bone will grow over the screws and make it more natural and solid.

I hope this helps and honestly feel free to ask anything!  Always happy to help!

Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: tony1233 on August 03, 2010, 10:07:19 PM
This forum sure is invaluable, I don't know what I would've done without it so far.

so at about 3.5 months I guess I can hope to be at AROUND the point where I can jogg again. We have an arena here with a track around the top of it where I ould go so that sounds like a safe place to do it. I won't be able to benefit from any of those things until the begining of next season beause We'll be under snow by the time I'm ready for that ;).

I was curious about the attachment because my OS is going to attach my tibial attachment with the bio-absorable screw but, my femoral attachment is a combnation of the screw and a "button" . I was just curious if you had any experienc ewith the button or not!

how strict was your protocol ? I found one on here that my PT seems to like but, we're not 100% sure if the OS has her own guidelines or not.  Me and the PT are prepared just in case she doesn't.

Really appreiciate you answering my questions, I'm getting a bit nervous now, only 8 days left til the OP.

Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: orthosci on August 04, 2010, 01:01:47 AM
The trick is to get the ingrowth of blood vessels so that the graft can remodel. You need to pump blood into the knee.  Running is an opening and closing joint jarring motion which is a problem if you have other injuries.  Most ACL injuries have concomitant injuries such as meniscus tears or cartilage defects, neither of which when repaired or resected like running. 

Most of the capillaries that service your connective tissue (the parts that hold joints together) are growth capillaries and when you quit growing, at about age 25, their ability to deliver oxygen to cells diminishes over time.  What that means is that if you are older you have to bend you knee a lot more times than a younger person does in order to get the same amount of oxygen to the cells. This is where stationary bicycling comes in.  Nordic track works also because, unlike running, it is a gliding motion, however, when your torso is parked on a bike, the knee isn't supporting your weight and you can bend the knee a lot without making it angry.

Two rules of pain; if it begins to hurt, stop what you are doing.  If it hurts within 24 hours, you've overdone it.  In either case, reevaluate what it was that you did that was different from the last time that you did PT and back off a bit. Since PT is an activity that you gradually increase both the type and duration over time, when adding a new type of activity or increasing time, do it weekly and not daily, then you don't have the risk of getting an overuse injury - tendonitis for example - in a brand new graft that is neither totally vascularized much less remodeled.

Rehab is a modified more is better model, the more that you bend the knee the better.  No squats, cybex testing, extension against resistance, all of which load the knee and that brand new ligament.  Better to use the bike on low loads and be able at 3 months to put 30 minutes in 2x a day than trying to run the same amount.  What the knee needs is to be vascularized and making it angry so that it hurts will cause inflammation and effusion (swelling) and cause injury secondary to the effusion that you will then have to recover from.

Cryotherapy is your friend.  In addition to being able to assist in the reduction of swelling, it has an analgesic effect that can be used to reduce pain even when the knee isn't swollen.  So whenever you change your routine and the knee lets you know about it whether it be 2 weeks out or 2 months or 6 months or a year, cryotherapy can be helpful to stop the inflammation/pain cycle. 

While the stationary bike and Nordic track are excellent rehab devices, their in vitro counterparts, biking and XC skiing can pose problems depending on how long post-operatively you begin using them.  Unlike when the knee starts hurting and you are on a stationary bike or Nordic track where you can quit and get off, if biking or XC skiing some distance, that option has limits and guys (I'm a man - I can take it) often make the wrong choice and keep going and thus develop a good case of new graft tendonitis.  This is Bad News - don't do it.

Anything that you do that is not low load high rep capable, like biking or NT, really isn't great ACL PT.  Rather it is a recreational activity that has limited physical therapy utility.  The problem in the education portion of this distinction is that Docs often call PT 'exercises' and everyone often calls recreation activity 'exercise'.  You can see how it is easy for people to get confused.  Most ACL PT is designed around a 2 dimensional model because that controls the load on the knee during it's weakening (lowest, weakest point at 4 - 6 weeks) and dominant revascularization & remodeling interval up to about 6 months.  3 dimensional movements, such as rapid direction changes - cutting or jumping and landing, are capable of putting more load on a new graft than it is capable of withstanding without incuring injury. 

For most graft models, the graft doesn't obtain relative strength to the original ACL until about 9 months. It is sort of like being pregnant in reverse, though I don't think that an ACL reconstruction is nearly as bad as giving birth.  However, while a pregnant woman might jog in her first trimester, so may an ACL reconstructed patient jog in the last 3 months, and the middle 3 months are more iffy for either example and are dependent on how careless you are, how uneven the ground is, what other kind of injuries you have, and what your body mass is;  all are factors that should be weighed into the equation when making the decision to run.  Again - it ain't PT.

If you want to do 3D PT, get in the pool.  Same 2 rules of pain, start off slow and see if it is angry the next day or not.  Crawl stroke kick isn't necessarily good because in extension, while the ACL is in the roof of the intercondylar notch, the load, when against the heel, can make the new graft unhappy in a relatively short distance.  It is never a race, use flotation if you don't swim well, and a mask and a snorkel if the chlorine or other pool cleaning agents bother your eyes or sinuses.  Work on symmetry and economy of motion.  No speed or long distances.  The 3D breast stroke kick has the benefit of overcoming proprioreception loss and leg muscle ratio of strength disparity.  Be patient as it will take months.  Plus, rice crispy knees (snap, crackle, and pop) generally will love the pool and so will the rest of your body.

For you Tony, "femoral attachment is a combination of the screw and a "button" ", The button is probably an endopearl, a little bioabsorbable round bead that is tied to the fold in the graft so that the graft can't be pulled past the screw because the interference screw positioned in the tunnel alongside the graft won't let the "button" pass under load.  I've got an Achilles allograft in my knee sized to 9mm inside a 10mm tunnel with a 9mm x 25 mm bioabsorbable interference soft thread screw.  The tibial end has the bone plug in a 12 mm tunnel with a 7 x 25 mm bioabsorbable interference screw.  I'm 21 months out and the knee is stable.

The strictness of your protocol question is telling me that you'd like to do what you want but have your recovery be optimal in spite anything that you might do or not do.  That reminds me of what my doc tells me about his teenage patients who all seem to think that the laws of physics and biochemistry apply to everyone but them. 

It will take longer than you think.  It will take more time than you think.  If you consider that getting it right the first time and investing the time and being careful for about a year (or so) so that you might not have to have it done again then you'll be more likely to have a successful outcome that YOU like the first time around.

Do straight leg raises 500 a day, start now. Tighten the leg, raise it 4 to 6 inches, put if back down, relax it. Do it again, 499 to go.  You can do them standing up, sitting down (gotta scoot forward to be able to keep the leg straight), or laying down.  You can't do them and count them while computering, reading, talking on the phone or watching tv, so don't count them, just do them.  If you do 5 minutes on the hour, that will get you 500  in about 10 hours and then it will just become a normal thing to do instead of trying to do them all at once over 35 to 45 minutes or do.  Follow the 2 rules of pain on this too.  When you can do 500, then do 600, and then 750, and then after a while 1000. They will build you quadriceps muscle back up and keep your graft safe while it is in a weakened state.  More is better, but follow the two rules of pain.

Good luck,

p.s.  Allografts are where it's at.  Robbing Peter to pay Paul (autografts) is not a particularly good idea since God didn't make us with any spare parts. 
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: tony1233 on August 05, 2010, 02:42:54 PM
Thank you for the very informational post.

I will be sure to refer to this as time goes on throughout my rehab process. However I know the laws of physics and biochemistry do apply to me, I was just curious as to when Jay started moving on to bigger parts of his rehab, ie. Jogging. I haevn't really been able to jog since january and I really miss it. I'm so out of shape now it's absolutly rediciouls. I just wanted to see when I can hope (around about) to get back at the exercises I really enjoy.

Less than a week from now I'll have my operation completed and will be posting a post-op diary and It'll be interesting to see how my recovery compares to yours, Jay's and everyone elses on the site.

All the best,

Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: jamiec123 on August 09, 2010, 09:56:49 AM
Well good luck with the op Tony and make sure u post as soon as u can to let us know how it went!!

Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: tony1233 on August 09, 2010, 02:46:46 PM
Thanks Jay,

getting excited and nervous now, o nly one more night of sleep, if you can even call it that at this point. I know I havenèt really slept well in the last few nights so Im sure I wont sleep tomorrow night at all ;)

I plan on trying to post wednesday evening, not 100% sure how well that will go though LOL please forgive if nothing makes sense.

Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: ACLDad on September 11, 2010, 02:10:47 AM
I am new hear.  My 18yr old college freshman tore her acl a month ago.  Her doctor did a anterior tibial allograft.  I am not sure of the attachment method he used.  Everything happened so fast we had about 10 days from the tear to the surgery.  Now we hear all of these horror stories about allograft failures happening all the time.  Am just looking for some reassurance here.  I want to thank Steve for his excellent advice.  It would seem that there is no need to try to return as quickly as possible but rather resign yourself to 8 to 12 months to let the graft (regardless of allo or auto) fully vascularize, and at her age the chances of that occuring fully are good right.

Tony - ACLDad
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: drmark on February 14, 2011, 04:22:08 AM
I don't think the "allograft is where its at"
Finally, a multicenter study, with a minimum of 6 years followup, and Level 2 evidence.  (Level 1 evidence may not be possible to procure considering it would be unethical to not inform patients what was implanted in them)

Sorry to bust the bubble.........
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: sherwooa on March 25, 2011, 12:34:26 AM
So that MOON study is definitely interesting, and I can't see the full text, but I have read elsewhere ( that this study only compares tibialis allografts with hamstring autografts.  Given that, it doesn't seem scientifically valid to say that all autografts are superior to all allografts, especially since many allografts now are done with B-P-B instead of free tissue.  Thoughts?
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: drmark on April 10, 2011, 12:43:36 AM
If you are interested, you can email me at [email protected] and I will forward to you the entire PDf.  Many different autografts and allograft types were used in the study.  For purposes of analysis the autografts were grouped together and the allografts were grouped together. 

In my not so humble opinion, the hopes, prayers, and desires of the immediate world will never be answered that dead tissues taken from a dead person, soaked in caustic stuff to kill the  "cooties", or worse irradiated, can ever work as good as living tissue taken from the person who is receiving that same tissue.  Even as we continually grasp at straws in order to show it.  When will nutrasweet and skim milk be shown to make a dessert as tasty as the one made with real sugar and real cream?
Mark Sanders MD FACS
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: nathanappasamy on May 13, 2011, 10:59:59 AM

Hello everybody,

I am looking for people who have had Anterior Cruciate Ligament Reconstruction on at least one of their knees to take part in a study focusing on the effects and impact of ACL Reconstruction surgery on someone's Athletic Identity.

As someone who has had multiple knee surgeries, I am very interested in the psychological effects of such mobility impairing surgery and do not believe there has been enough research undertaken in the field. The hope for this study (which is part of an MSc in Psychology) is to provide a greater insight into the short term and longterm effects of ACL reconstruction on a person's sense of Self and Identity. If you have had ACL reconstruction surgery and would like your experiences to count towards our understanding within the field, your contribution is of value.

If you would like to take part in the study (which should take no longer than 15 minutes to complete), please click on the below link for further information. Alternatively, copy and paste the link directly into the address bar of your browser. If you know of anyone who may also be interested, then I would be grateful if you would notify them of this opportunity to participate:

If you have any questions (which are not answered by the information sheet, after clicking on the link), please contact me by email at [email protected], and I'll be happy to help.

Nathan Appasamy
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: sherwooa on January 05, 2012, 05:00:30 PM
Thought I'd post some of the recent research on auto vs. allo, though it adds to the confusion a bit.  Though not as big as the MOON study, here is a recent prospective, multicenter cohort study with Level II evidence that shows no statistically significant differences between the two types of grafts:


To compare the clinical outcomes after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone autograft (BPTBAu), BPTB allograft (BPTBAll), or hamstring (semitendinosus-gracilis) tendon autograft (HTAu), performing bone drilling with same methods in terms of transtibial drilling, orientation, positioning, and width of femoral and tibial tunnels.
Multicenter prospective cohort study (level of evidence II).
Departments of Orthopedic Surgery of Centro Médico Teknon (Barcelona, Spain) Clínica Universitaria de Navarra (Navarra, Spain), and Clínica FREMAP (Gijón, Spain).
All patients with ACL tears attending 3 different institutions between January 2004 and June 2006 were approached for eligibility and those meeting inclusion criteria finally participated in this study.
Each institution was assigned to perform a specific surgical technique. Patients were prospectively followed after undergoing ACL reconstruction with BPTBAu, BPTBAll, or HTAu, with a minimum follow-up of 24 months.
Included knee laxity and International Knee Documentation Committee (IKDC) score. Knee laxity was assessed with the KT-1000 arthrometer (evaluated with neutral and external rotation positions) and both Lachman and pivot shift tests. Additional outcomes included main symptoms (anterior knee pain, swelling, crepitation, and instability), disturbance in knee sensation, visual analogue scale (VAS) for satisfaction with surgery, range of motion (ROM), and isokinetic knee strength.
There were no significant differences among the 3 groups for any of the clinical outcomes, except for a slightly greater KT-1000-measured knee laxity in external rotation in the BPTBAu compared with the other groups. All patients demonstrated grade A or B of the IKDC. The mean VAS for satisfaction with surgery in all patients was 8.5.
The selection of the surgical technique for ACL reconstruction may be based on the surgeon's preferences."
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: filamentary on October 05, 2014, 06:39:26 AM
Allografts are where it's at.  Robbing Peter to pay Paul (autografts) is not a particularly good idea since God didn't make us with any spare parts. 

i don't agree that allografts are where it's at, at all.  they're great for older patients, or patients who don't do a lot of vigorous/challenging physical activities.  basically people who only use their legs for walking, and maybe do a little family-friendly hiking with the kids or grandkids.  but they have a crazy high failure rate in young and athletic people.  i just keep seeing disheartening story after disheartening story of people who've had multiple ACL reconstructions.  most people will never tear an ACL once in their lifetime.  it's not exactly a high-frequency injury.  it's already unfortunate that we only have one ACL and it can't regenerate.  but the whole idea behind reconstruction is that you should be as prepared for the world and sports activity as you were with your original, not some weaker, less-prepared version of yourself, where it's just a matter of time before this sad, inadequate little thing snaps.

with autografts, you often end up with an ACL that's stronger than it originally was.  and the loss of strength to the hamstrings is pretty minimal, and able to be compensated by training the muscles.  perhaps if you are a competitive lifter whose major competitive lift is the romanian deadlift, you might be put out by this, but the loss of strength isn't enough to make you incapable of having a strong, muscularly balanced and well-protected knee.  you can't compensate or train away laxity or weakness in a ligament.  frankly i'm surprised there are so many doctors willing to do allografts as often as they seem to be getting done.  sure, it's scary, and it's a longer recovery, having tissue harvested from your own body.

but if you're going to have ONE little broken thing in your knee, why not just be missing two measly little tendons from your hamstrings, which operate quite well without them (the three they don't harvest are way more massive and important to the hamstrings' function), rather than be missing the very important ligament inside your knee?  doing a hamstring autograft is basically just shifting the injury from inside the knee joint capsule to the back of the knee, to the hamstrings, but also while diminishing the severity of the injury.  you can't change that you permanently injured your knee, and that it will never be the same knee you had before the injury.  but with a hamstring autograft, you can shift the damage to the big, strong hamstring, which easily absorbs the damage b/c of all the redundant working-together fibers (unlike the lonely ACL).  and also the literature shows that one of the two harvested tendons is actually starting to be recognized as having regenerated (even though it is often repeated that lost tendons are just lost forever)!  so you're really only short one tendon, and have one (perhaps slightly less good than original due to surrounding scar tissue) regenerated one.  that seems like a really excellent compromise.

having multiple subsequent re-tears of the ACL and additional reconstruction surgeries (each time, taking a full year out of your normal life, and enduring some of the most awful pain and immobilization it's possible to have, plus adding more and more scar tissue which is increasingly understood to be the main source of all pain and mobility issues over the long term), this seems like a terrible alternative.  and this is exactly what a huge percentage of allograft patients have in their future.  why not skip the whole mess?  if the replacement ACL is as strong as the original, then it's just as unlikely that it'll break the second time as that it broke in the first place.  it's just as likely that they'll tear the OTHER leg's ACL as that they'll re-tear the graft.  well, i guess i'd be amiss not to acknowledge that having a dominant foot might make one leg more likely to be injured in a given sport than the other due to certain ways of holding the body in situations where collisions or falls tend to occur.

i mean, assuming they follow medical advice and heed the one-full-year-to-full-recovery guideline (some people really push it trying to get back to sports too soon, and while i understand the desire to do this, if it re-breaks, they shouldn't be surprised) they should fix their ACL and put a tremendous amount of effort, over the following year, into recovery (including strength training), then that should be it, they should never have this problem again unless they're supremely unlucky a second time.  but with allografts, they're way more likely to tear it again (more likely than they were before the ACL reconstruction, and more likely than their never-ACL-deficient teammates).  it just seems like too small a payoff (a slightly shorter/less painful initial recovery, but still followed by a full year of waiting for the graft to "take" fully) to trade out a permanent, once-and-done fix versus one you have to repeat, time and again, thus actually adding up to far more cost, recovery time, and total time spent immobilized and suffering.

i have researched the HECK out of this thing before my own surgery, and all the best doctors and institutions seem to be leaning this way.  especially in the knees that are most in need of being returned as close as possible to original condition and capability, like professional athletes.  and if it's the best for them, it's also the best for the rest of us (except, as i mentioned, people who basically only use their legs for walking).  i'm really surprised to find someone here prominently advocating allografts, when they have such a high failure rate.  especially b/c it's easy to be swayed toward thinking you want an allograft out of fear of the harvest site pain, but really people need to be reassured that it's better to get back a functional ACL and have a teeny bit of injured hamstring tissue, and NEVER revisit the problem again.  this seems way more responsible than the alternative, which so often ends in multiple surgeries.
Title: Re: Graft Choice in ACL reconstructions - The Place of Allografts
Post by: healingup on June 22, 2016, 10:32:17 AM
With Lars u can return to sports much sooner than with allograft/autograft. HOWEVER, syntetic grafts are not living tissues so it can only break down. Living tissues have the ability to remodel, repair to a certain extent etc. So it is still not know whether lars hold for your entire life. 10 year follow up is fine but it is the 40 year that u are interested in. If u can offord to take it easy for one to two years I would go for the allograft.